Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | WV |
NPI | 1154585941 |
---|---|
Provider Name | Mrs. Mary Jane Tudor |
First Address | Sophia, WV 25921 |
Second Address | Sophia, WV 25921 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2008 |
Last Update Date | 11/07/2008 |